Resource – Page 424

Hobby Lobby case: Another reason to go beyond ACA

By Michelle Teheux
Pekin (Ill.) Daily Times, July 1, 2014

The Supreme Court just presented us with the best-possible argument in favor of a single-payer health care system.

Rather than the Affordable Care Act, the single-payer option would offer some big advantages, such as nixing employers’ attempts to control what kind of birth control their employees use.

Switching to single-payer would mean these decisions could again be made by the individual in consultation with his (in the case of vasectomies) or her doctor, rather than having to take into consider what the employee’s corporate overlords considered the correct method of contraception.

I’m not unsympathetic to the religious views of those who don’t agree with one method of contraception or another. I think it’s important to note, however, that corporations don’t have any religious views. Only people have religious views. Also, the employer is providing insurance as part of a benefits package the employee has earned. Nobody is giving away health insurance to their employees as a gift, any more than they are giving away paychecks. The employees are earning their money and benefits, and if they decide to stop showing up for work, their employer will stop providing pay and insurance forthwith.

We need to remove employers from the health care debate altogether. It isn’t any of their concern whatsoever whether their employees choose one form of birth control or another. The appearance that they are paying for the contraception (even though they really are not) has served to give them a voice they shouldn’t have.

Imagine if we paid for national defense through payroll deduction. You’d have some people insisting they did not want any of their money to go toward purchasing weapons. Others would say they were OK with throwing their money toward guns, but no bombs. Or rocket launchers are OK, but absolutely no nukes. Etc.

We are all funding things that we don’t agree with, because there’s no way to always be fair. Sorry to break that to you.

Single-payer has always been my first choice of a health care system. It works well in many other countries, where the citizens are mystified by so many Americans’ all-out panic at the idea. We stubbornly insist we have the best health care system in the world, even though a tiny bit of research would show that other countries spend far less per capita on health care and have far better outcomes. It’s willful ignorance.

I never thought the ACA was the last word in health care. I always hoped we’d eventually get to single-payer, and maybe the ACA could be a step toward that eventual goal.

One thing we wouldn’t see, with single-payer, is any corporation trying to convince anybody that it couldn’t stand the idea of being involved in any way with a woman choosing to use contraceptives, because the money would be muddled up much the way money going toward munitions is muddled up. I can’t say my tax dollars explicitly went toward buying the bomb that drone dropped. I couldn’t say my tax dollars explicitly went toward helping pay for birth control pills for that woman who is in no way prepared for motherhood.

And one more thing. Let the 99 percent of us women who have used birth control stop being embarrassed to talk about it. Yes, sometimes some of us have used the pill to regulate our menstrual cycles or to clear up severe acne or to treat endometriosis, and some of us have chosen to have our tubes tied or our husbands have chosen vasectomies because we have a serious medical problem that would make pregnancy dangerous.

But for most of us, we use contraception simply because we don’t want to get pregnant at this particular time, or perhaps not ever, and we are having sex for reasons of pleasure and intimacy, not reproduction.

That’s the reason why almost everybody has sex, and it’s why we need effective contraception available to every single person who wants it.

The Affordable Care Act ought to have accomplished that. Since it can’t, all the more reason to move on to single-payer.

Michelle Teheux is editor at the Pekin Daily Times.

Read more: http://www.pekintimes.com/article/20140701/Opinion/140709850#ixzz36KJpmhOS

Evidence supports single payer

By Ellen Oxfeld
Rutland (Vt.) Herald, July 2, 2014

In his recent column on health care (June 29), John McClaughry criticizes Vermont’s road map to universal health care as laid out in Act 48. This road map hopes to create a publicly financed health care system, in which health care is a guaranteed public good for all Vermonters The target date for implementation is 2017.

According to Mr. McClaughry, the recent VA scandals, in addition to evidence from Canada and other countries where health care is universal and publicly funded, shows that such systems will result in “rationing, wait lines, maddening bureaucracies, inefficient work rules, demoralized doctors and nurses, shabby facilities, obsolete technology, and declining quality of care.”

So, what is the actual evidence? According to the Commonwealth Fund’s 2014 report on 11 industrialized nations (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States), the United States ranked last on issues of access, efficiency, and equity. An interesting feature of this study is that it showed that even higher-income and insured Americans were often unable, as compared to those in other countries in similar positions, to get needed treatment. This may be due to the fact that even with insurance coverage, many Americans face high out-of-pocket costs.

Ironically, the United Kingdom ranked first in the recent Commonwealth Fund report. Their system is actually government owned and operated. However, we should be clear that Act 48 does not contemplate a government-owned health care system at all. Rather it proposes functioning much like our current Medicare system does, using publicly raised funds to pay providers, who remain in the private sector. (It is also important to point out that according to Act 48, the new publicly financed plan, Green Mountain Care, will function as a secondary payer or wraparound for those who are already on Medicare).

In any event, this recent data, and numerous other studies of comparative health care systems, leaves one wondering on what basis John McClaughry can assert that countries with publicly funded health care systems deliver worse care. He certainly cannot demonstrate that these systems are more expensive — as health care costs in the United States are the highest in the world. (According to the Fund’s report, we spend about twice as much per capita as the average for the comparison countries, and the same ratio holds true if one looks at health care spending as a percent of GDP). Over 60 percent of personal bankruptcies in the United States are due to health care expenses.

Finally, what about the issue of the VA? Independent surveys actually show that those who get into this system give high marks on the quality of care they receive. But gaining admittance is not easy. One has to prove that one’s ailment was a result of one’s military service. Furthermore, as Sen. Bernard Sanders has pointed out, more than 2 million more veterans are in need of care now, due to the wars in Iraq and Afghanistan. Certainly, these numbers mean that more investment is needed to guarantee timely care for all these veterans. But how does this prove that publicly funded health care is inefficient? This recent scandal seems to say more about our propensity to engage in costly military adventures overseas, and then to forget that we have to care for veterans when they return home.

The fact is that 45,000 Americans in the private health care sector die each year because they were unable to receive the care they needed. Why is this not a scandal? It certainly should be, especially when we consider that every other country in the industrialized world has been able to provide health care to their citizens more effectively in terms of cost and quality through some kind of public financing and universal inclusion.

Act 48 was a breakthrough for Vermont, and we should support the road map to guaranteed publicly funded health care for all Vermonters that it laid out. The evidence has shown time and time again that public financing and guaranteed universal access are the most effective ways to create an efficient, cost-effective, high-quality health care system.

Ellen Oxfeld is a resident of Middlebury.

http://www.rutlandherald.com/article/20140702/OPINION04/707029932

The Hobby Lobby Lesson: We Need To Fight For Single-Payer Health Care

By Emily DiVito
Campaign for America’s Future, July 1, 2014

Here is the clearest, and scariest, implication of the Supreme Court’s Monday ruling in Burwell v. Hobby Lobby, Inc.: The Patient Protection and Affordable Care Act – “Obamacare” – is fatally flawed. It is clear we now need a public, single-payer health care system – because the Supreme Court can no longer protect us.

The fact that Hobby Lobby Inc. actually had a legal standing to bring this case to court in order to contest providing comprehensive health care to their 18,000 employees should prove that a key feature of the Affordable Care Act is unsound: It relies too heavily on private entities to deliver a public good – health care.

The Hobby Lobby case was decided not under the constitutional rights guaranteed by the First Amendment, but under those dictated in the Religious Freedom Restoration Act of 1993, drafted to prevent laws that substantially burden a person’s free exercise of religion. Under that act, the government must prove that a law that hinders religious expression serves a “compelling state interest” and does so in the “least restrictive” way possible.

Justice Samuel Alito’s majority opinion concedes that the government has a “compelling state interest” in providing contraception, but claims the Affordable Care Act does not do so with the “least restrictive means” to achieve this end. Unacknowledged, however, is that there is almost no way to provide comprehensive birth control coverage in a minimally restrictive way to businesses without widening government jurisdiction over health care. If businesses will not pay for health insurance that covers contraception, then the government must.

This exposes the primary and unavoidable weakness of the ACA. Because it still requires that private companies enforce what should be considered public policy – health care – the ACA will always face potential legal contention with the personally held religious beliefs of employers.

Moreover, Hobby Lobby Inc., Conestoga Wood and Mardel were able to preserve legal standing before the court while completely ignoring science and reality. The Religious Freedom Restoration Act protects their religious liberty so thoroughly that all the Greens and the Hahns had to do was believe that the forms of birth control in question, including emergency contraceptives, caused abortions. But, they very obviously do not. The American College of Obstetrics and Gynecologists has maintained for years that “emergency contraception is not effective after implantation; therefore, it is not an abortifacient.”

Public policy needs to be based on empirical fact, not disproved or unproven beliefs. But we cannot do this until the American health care policy eliminates the role of private companies in administering public goods.

Intentionally or not, Justice Alito makes the case for an expansion of government control of health care. He maintains throughout his 49-page decision that the best way to ensure comprehensive birth control access under insurance plans “would be for the Government to assume the cost of providing the four contraceptives at issue to any women who are unable to obtain them under their health-insurance policies due to their employers’ religious objections.”

Ironically, this represents a potential increase in the scope of the federal government that most conservatives would protest – and did protest when the ACA and the public option (in which the government would offer a publicly funded insurance plan as an alternative to private insurance) were up for debate four years ago.

Justice Alito’s offered solution to the newly formed coverage gap is the expansion of an ACA “accommodation” currently in place for religious nonprofits. Via an exemption to the ACA crafted by the Department of Health and Human Services, employees of these nonprofits are still eligible for contraceptive coverage through their existing insurance companies directly, and not through their religiously affiliated employer. Justice Alito maintains that “HHS has provided no reason why the same system cannot be made available when the owners of for-profit corporations have similar religious objections [to contraception coverage].”

Interestingly, interest groups on both side of this debate rejected Alito’s alternative, albeit for completely different reasons.

Lori Windham, Senior Counsel for the Becket Fund for Religious Liberty and counsel for Hobby Lobby, maintains that the accommodation “fails to solve the moral problem created by the mandate for many religious organizations.”

Judy Waxman, Vice President for Health and Reproductive Rights at the National Women’s Law Center, said that expanding the existing accommodation would separate birth control from other health care drugs and services. “Birth control is a basic health service that almost all women in this country use for health care. And it is important that it be covered like every other service,” Waxman said.

President Obama seems to have taken note. When White House Press Secretary Josh Earnest was asked Monday afternoon if the administration was looking to expand the current ACA accommodation in place for religious nonprofits, Earnest simply said “no.” Instead, he affirmed that the ruling made clear “that there is an opportunity for Congress to take the kinds of steps that would mitigate this problem.”

Unfortunately for American women, congressional action is very unlikely to happen, even though there is plenty of fervor over the issue among Democrats. Senate Majority Leader Harry Reid (D-Nev.) took to the Senate floor Monday morning to declare “If the Supreme Court will not protect women’s access to health care, then Democrats will.”

There are various legislative solutions to the contraceptive coverage gap left by the decision, including giving the federal government the power and the funds to cover contraception specifically and amending the Religious Freedom Restoration Act. But none of these are considered viable options amidst the current congressional dissonance.

But something must be done. A single-payer public health care option should be reexamined to detach employer whims from public needs. We must minimize the influence of bosses and businesses in the implementation of health care. No one elected them.

http://ourfuture.org/20140701/the-hobby-lobby-lesson-we-need-to-fight-for-single-payer-health-care

The Hobby Lobby case proves the necessity of single-payer healthcare

By Michael Hiltzik
Los Angeles Times, July 1, 2014

Is there anything more absurd than the American way of delivering healthcare coverage?

Most Americans receive coverage through their employers. In the wake of Monday’s Hobby Lobby decision by the Supreme Court, businesses accounting for about 52% of all privately employed workers now have the option to discriminate among their employees and among the healthcare benefits they offer, based on their owners’ religious beliefs.

The U.S. reliance on employers to provide coverage on this scale is unique among major industrialized nations. In those countries, as Jonathan Cohn observes, “the government takes on this responsibility directly, by creating its own insurance program or regulating insurers as if they were public utilities.” This is essentially a definition of single-payer healthcare.

The alternative produces ludicrous results such as the Hobby Lobby decision.

It was hoped that the Affordable Care Act, which was at the center of that decision, would begin decoupling American healthcare from the tyranny of employer sponsorship. Americans who are out of work, or whose employers can’t or won’t provide them with healthcare benefits, now can buy coverage on their own, with government financial assistance if necessary.

This was a first halting step toward single-payer, which is more the norm in the developed world and plainly the most efficient and effective way of achieving universal coverage.

But it wasn’t enough of a step: The ACA still leaves most health coverage in the hands of employers. And it strengthens the hands of private health insurers in administering coverage and setting prices and terms for the doctors and hospitals providing care. The law was one step forward toward single-payer, and about three-quarters of a step back.

The Hobby Lobby decision underscores the patchiness of the ACA, by granting employers a huge loophole to avoid the law’s mandates — in this case, the mandate that coverage include reproductive services for women without deductibles or co-pays. At the center of the case were the evangelical Green family, owners of the Hobby Lobby retail crafts chain, and the Hahn family, Mennonites who own a wood furnishings firm. They asserted that the ACA’s birth control mandate offended their religious sensibilities; the court ruled that these sensibilities outweigh the ACA’s coverage standards.

As it happens, Justices Samuel A. Alito Jr. and Anthony M. Kennedy, in their majority and concurring opinions, respectively, implicitly acknowledged the wisdom of single-payer healthcare as a way forward.

They did so by advising the government to grant the business owners relief by establishing what is in effect a single-payer regime for the birth control methods at issue. (These are two “morning after” drugs and two forms of IUDs that the businesses term “abortifacients,” meaning they cause abortions.)

Rather than forcing the businesses to pay for those methods, the justices said, the government could follow the path it already has laid down for nonprofit religious organizations objecting to the birth control mandate. In those cases the coverage mandate and its cost are transferred from the religious employers to their insurers — but the insurers are compensated for the expense via a reduction in a healthcare tax they’re required to pay under the ACA.

In other words, the U.S. government becomes the single payer for those groups’ employees choosing those birth control methods. Alito and Kennedy would expand this accommodation to closely held businesses whose owners assert religious scruples.

The pertinent question then becomes: Why stop there? Offer the same accommodation for all employers for all coverage, and you have a single-payer system at last.

Among its virtues, a single-payer system would eliminate the subjective uncertainties about healthcare coverage that the Hobby Lobby decision intensifies by imposing a religious standard on that coverage.

A key problem with the religious standard is the difficulty of validating someone’s “beliefs.”

The majority and dissenting opinions in Hobby Lobby both bowed to the “sincerity” of the business owners’ religious beliefs. But this was just lip service, not a conclusion drawn from empirical data.

“The Hahns and Greens and their companies sincerely believe that providing the insurance coverage … lies on the forbidden side of the line, and it is not for us to say that their religious beliefs are mistaken,” Alito wrote. But how could he possibly know?

Even assuming, for argument’s sake, that these families aren’t hypocrites in their personal lives, how are the courts to judge the sincerity of the next employer who comes forth with a “religious” objection to some aspect of the ACA, or to some other federal law?

Alito didn’t provide lower courts with a test to appraise piety. How could he? There’s no concrete definition of “religious belief,” which means there are no practical bounds to employers’ ability to pick and choose which laws they will honor.

One thing that is clear about the beliefs of the business owners in Hobby Lobby is that, regardless of whether they are sincere, they certainly are medically ignorant.

Alito acknowledged that the families’ claim about the four contraceptives being “abortifacients” isn’t a judgment based on science or medical practice, but on “their religious beliefs.”

In scientific terms, these beliefs are nonsense. That point was made crystal clear in an amicus brief filed by 11 organizations of reproductive health professionals, including the American College of Obstetricians and Gynecologists. They advised the court that the contraceptive methods challenged by the business owners are not, in fact, abortifacients. Alito acknowledged that they’re not classified as such by the Food and Drug Administration.

So the bottom line of the Hobby Lobby decision is that the provision of medical care to millions of American families will be contingent on feelings of their employers that may or may not be sincere, that have no practical limitations, and that have no grounding in medical science.

The only way to resolve this mess is to take employers and their “sincere beliefs” completely out of the picture — as Alito and Kennedy recommend. Remove employers and the insurance industry exits with them. What’s left is single-payer healthcare, which is the right way to deliver services that are matters of life and death.

http://www.latimes.com/business/hiltzik/la-fi-mh-singlepayer-healthcare-20140701-column.html?utm_campaign=KHN%3A+Daily+Health+Policy+Report&utm_source=hs_email&utm_medium=email&utm_content=13360146&_hsenc=p2ANqtz-8IIOgi45vAZJq6XrZgHqiyosFxmRa2tt_MfHp_SC_4jTx811OrNhIPzGgvyQvMIPKm8h5tlCNwM-A9WetfysxgsS2w5A&_hsmi=13360146#page=1

Massachusetts Single Payer Fact Sheet

By PNHP-Massachusetts and Mass-Care

272,000 Massachusetts residents lacked health insurance in 2012, 4.1% of the population. (Source: U.S. Census Bureau)
About 300 adults die from lack of health insurance coverage annually in the state. (Ann Intern Med 2014;160:585 & AJPH 2009;99:2289).
At least 530,000 Massachusetts residents under age 65 are under-insured, meaning they have coverage, but still devote a large share of income to cover costs including copayments and deductibles. Many more lack adequate coverage for long-term care or mental health services. For 618,000 with private coverage, their premiums are so high that they’re unaffordable, according to federal guidelines. (Commonwealth Fund 2014)
Massachusetts’ per capita health costs are about 30% above the national average and continue to rise. Between 2009 and 2011 private insurance premiums in Massachusetts increased 9.7% despite a 5.1% fall in benefit levels – effectively a 14.8% cost increase. (CMS Office of the Actuary & Mass. Center for Health Info. and Analysis)
Federal, state and local governments already pay about 64% of all health costs in Massachusetts, which totals about $8,500 per resident in 2014. This figure includes health benefits for public employees and tax subsidies for private insurance, as well as government programs such as Medicare and Medicaid. That’s more than total (public + private) health spending in any other nation. (Health Affairs, 2002;21(4):88 – updated by the authors)
Surveys show strong support for single-payer. Nationally, 56% of adults favor a “universal program like Medicare” (ABC/USA Today/Kaiser survey, 2006) and one-third of those opposed to Obamacare say its “not liberal enough” (CNN/ORC survey, May, 2013). Among Massachusetts doctors, 60% favor single payer or public option, a policy that many conflate with single payer (Mass Medical Society Survey, October, 2012).
Single-payer health insurance in Massachusetts could save about $12.3 billion annually on paperwork and administration (NEJM 2003;349:768-75 Updated by authors). Separate studies commissioned by the Massachusetts Medical Society and the state legislature found that the administrative savings under single payer would be large enough to cover all of the uninsured, eliminate all co-pays and deductibles, and upgrade coverage for Medicare enrollees – without any increase in health spending.
1. Massachusetts’ three largest private insurers (Blue Cross, Harvard Pilgrim and Tufts) employ about 6,600 workers to administer coverage for 5 million people (Companies’ annual reports, Boston.com and Patriot Ledger). That’s more people than work for the Center for Medicare and Medicaid Services, which administers coverage for 49 million Medicare enrollees and 51 million Medicaid enrollees. Nationally, private insurance overhead averages 12% vs. traditional Medicare’s 2.1%.
2. At present, Massachusetts hospitals devote on average 24.0% of total expenditures to administration, about double the percentage for hospitals in nations with single payer systems which greatly simplify billing and the documentation that private insurers require. (Himmelstein and Woolhandler analysis of 2012 Medicare cost reports, and NEJM 2003;349:768-75). Reducing hospital administration spending to the levels in Canada would save about $3.4 billion annually.
3. The complexity of the current payment system forces doctors and clinics to spend less time on patient care and to waste money and time on billing-related documentation and paperwork.
Whatever their other merits, the ACA and the 2006 Massachusetts reform have increased administrative costs.
1. In Massachusetts, the costs of running the Connector have added an additional 2% overhead (on top of the private insurers’ overhead) to the policies it sells.
2. Nationally, the cost of setting up exchanges exceeded $6 billion in 2013. That’s about $750 for each of the 8 million people who enrolled through exchanges by March 31, 2014.
3. In contrast, the cost of getting Medicare up and running in 1966 was $867 million (in current dollars). But that figure includes the cost of administering payment for the 18.9 million Medicare enrollees, and also doesn’t subtract the $376 million in overhead that was saved on the programs Medicare displaced. In other words, the net startup costs for Medicare were $491 million, or $26 per enrollee. The original Medicare sign-up form is reproduced in its entirety below.

If you would like more information, please email pnhp@bu.edu or director@masscare.org

Anthem Blue Cross punishing patients and providers for their own error

Error on Anthem ID cards results in claim denials

California Medical Association
CMA Alert, June 30,2014

In late March, the California Medical Association (CMA) began receiving complaints from physicians in San Diego, Orange and Bay Area counties about denials from Anthem Blue Cross. Practices reported that patients presented to their offices with Anthem ID cards that indicated they had a Covered California/mirror PPO product and subsequent eligibility verification also indicated the patient had a PPO product.

However, Anthem later denied the claims stating the services were not covered under the patients’ benefit plans because they received services from out-of-network providers.

CMA escalated the issue to Anthem and learned that while the Anthem ID card and eligibility verification indicated these patients had purchased PPO products, it was a mistake. These patients had actually purchased EPO products, with no out-of-network benefits.

While Anthem is offering a PPO product for their Covered California/mirror patients in most counties, they are only offering an EPO product in San Francisco, Los Angeles, Orange and San Diego counties. The Anthem EPO product does not provide any benefits if patients receive services from out-of-network physicians/facilities.

At CMA’s urging, Anthem corrected the affected patient ID cards and reissued new cards to EPO patients in May. Anthem also confirmed they have updated the information that displays when physicians verify eligibility to accurately reflect the correct product type.

CMA requested that Anthem automatically reprocess affected claims at the PPO rates, the product the ID card and eligibility information reflected, but Anthem was unwilling to do so. Instead they are requiring patients to appeal each individual claim to Anthem.

http://www.cmanet.org/cma-alert/archives/2014/june-30-2014

Anthem Blue Cross made a mistake in that they provided ID cards and eligibility verification for their EPO (exclusive provider) patients that indicated they were PPO (preferred provider) patients. PPO patients can obtain some care out-of-network but with reduced benefits. EPO patients are not eligible for any benefits out-of-network.

The California Medical Association has requested that Anthem Blue Cross reprocess those claims based on the PPO status that they had verified. Anthem has refused to do so, insisting that each claim be appealed individually. For an industry noted for administrative excesses and placing an administrative burden on health care providers, they are carrying it to an extreme wherein they are requiring much more administrative excesses to rectify their own error – punishing patients and providers for their own mistake.

How can this industry be so crass? Yet this industry, which should be placing patient service above all else, places its own business interests first. Such an insensitive response would never take place if our health care financing system were to be managed by our own public administrators. EPOs wouldn’t even exist. It’s time to replace the private insurers with a publicly-administered single payer system.

UnitedHealth’s Premium Physician Designation Program is not about quality

UnitedHealth Premium® Designation Program

The UnitedHealth Premium® physician designation program uses evidence-based, medical society, and national industry standards to recognize physicians for providing quality and cost efficient care.

The following designation results are displayed publicly in UnitedHealthcare’s physician directories (e.g., myuhc.com) to support informed decision-making by members when making health care choices and by physicians when making referrals.

Designation information is as follows:

Quality & Cost Efficiency
Cost Efficiency & Not Enough Data to Assess Quality
Quality & Not Enough Data to Assess Cost Efficiency
Quality & Did Not Meet Cost Efficiency
Not Enough Data to Assess Quality & Did Not Meet Cost Efficiency
Not Enough Data to Assess
Not Evaluated
Did Not Meet Quality & Cost Efficiency

Innovative Benefit Plan Designs

In addition, employers may offer health benefit programs (e.g., reduced cost-sharing or tiered benefit programs) that provide benefit incentives for members to use UnitedHealth Premium Tier 1 physicians.

Members in health plans that offer tiered benefits may pay lower co-pays and co-insurance amounts for services provided by UnitedHealth Premium Tier 1 physicians.

UnitedHealth Premium Tier 1 physicians have received one of the following Premium designations:

Quality & Cost Efficiency
Cost Efficiency & Not Enough Data to Assess Quality

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=a7b0465138a17210VgnVCM1000002f10b10a____

****

UnitedHealth Premium® Physician Designation Program

Summary Methodology

The UnitedHealth Premium physician designation program uses clinical information from health care claims and other sources to assist physicians in their continuous practice improvement and to help consumers make more informed and personally appropriate choices for their medical care.

Evaluation for quality compares a physician’s observed practice to the UnitedHealthcare national rate among other physicians who are responsible for the same interventions. Cost efficiency is assessed by comparing the case-mix adjusted cost of care attributed to the physician to a benchmark and applying a statistical test to determine if the difference is statistically significant.

Quality is the fundamental measurement, demonstrating our commitment to evidence-based practice. The quality designation is separate from the cost efficiency designation. Although the quality and cost efficiency evaluations are performed separately, the results are used together to determine the physician’s designation.

Physicians who meet both the quality and cost efficiency designation criteria will receive the quality and cost efficiency designation. Physicians who meet the quality designation criteria will receive the quality designation regardless of their cost efficiency evaluation. Physicians who meet the cost efficiency designation criteria will receive the cost efficiency designation if they do not have enough data to assess quality.

Quality Assessment

A physician’s quality individual outcome is determined by comparing the number of times his/her patients received recommended care with a benchmark number based on the UnitedHealthcare national rate of the same recommended care for each quality measure.

Cost Efficiency Assessment

Episode cost measurement compares a physician’s observed costs for episodes of care to a peer group’s costs for similar episodes of care, with adjustments for the patient’s severity of illness and the physician’s case mix.

For both episode cost and population cost measurement, the physician’s costs within each set are evaluated against their peer group’s costs by ordering the costs from lowest to highest cost. The costs are converted into percentiles to allow comparison across different types of cases or patients.

Physicians’ costs must be statistically significantly lower than the peer group’s physicians at the 75th percentile performance for all physicians (measured in the same specialty for the same types of episodes in the same geographic area) in order to meet the episode cost measurement criteria.

UnitedHealthcare informs members that designations are intended only as a guide when choosing a physician and should not be the sole factor in selecting a physician. As with all programs that evaluate performance based on analysis of a sample, there is a risk of error.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Unitedhealth%20Premium/UnitedHealth_Premium_Summary_Methodology_2013-2014.pdf

****

Comment:

By Don McCanne, MD

The perennial promise of private health insurers is that their insurance products would bring us higher quality care at lower cost, even though there is a paucity of evidence to support such claims. UnitedHealth now claims to be serious about delivering on that promise with their new Premium Physician Designation Program. They say that “quality is the fundamental measurement.” But let’s sort through their program description to see what the truth really is.

You can consult the websites at the links above for the detailed descriptions of how determinations of quality and cost efficiency are made. Although they state that quality is the fundamental measurement, they combine that with cost efficiency measurements and then use this information to classify each physician in one of the eight categories listed above. There are really only two designations that physicians can receive: quality and cost efficiency. If the physician receives either one or both of these designations, then these honors are displayed publicly in UnitedHealth’s physician directories.

Those designations might be nice, but what the patient really wants to know is if their physician is a Tier 1 physician. In plans that offer tiered benefits – very commonplace today – plan beneficiaries pay lower co-pays and co-insurance when they use Premium Tier 1 physicians. So what determines whether on not a physician is in Tier 1?

Of the eight categories listed, only the first two will qualify the physician as Tier 1. Either the physician must receive the designations of “Quality & Cost Efficiency” or “Cost Efficiency & Not Enough Data to Assess Quality.” Although quality is the “fundamental measurement” and is determined before cost efficiency, it is important to note that the third category – “Quality & Not Enough Data to Assess Cost Efficiency” – will not qualify a physician for Tier 1. The only way to become a Tier 1 physician is to be cost efficient; quality does not count.

It is also important to understand that even if all or almost all physicians are actually cost efficient, they are compared to their peers. “Physicians’ costs must be statistically significantly lower than the peer group’s physicians at the 75th percentile performance for all physicians.” It is impossible, no matter how efficient they are, for all physicians to gain Tier 1 status.

Further, the health care market in the United States is by far the most expensive of all nations, not only because of our prices but also due to our inefficiencies, especially our profound administrative waste. Favoring prices at the lower end of a highly inflated health care market falls far short of what we need to do to improve efficiency in our health care purchasing.

Thus UnitedHealth, for Tier 1, is selecting the cheapest physicians in an overpriced and inefficient market, regardless of the quality of their care. “Higher quality at lower cost” is a fraudulent marketing slogan of the private insurance industry. We need to throw these con artists out and replace them with our own efficient, quality-driven single payer national health program. The sooner the better.

HIP Replacement 2.0, or ‘Onward with Healthcare Expansion’

By Rob Stone, M.D.
The Herald-Times (Bloomington, Ind.), June 30, 2014

Grassroots activists across the state, including Bloomington-based Hoosiers for a Commonsense Health Plan, have been working for the past 20 months to build support for the expansion of Medicaid to low-income Hoosiers under the Affordable Care Act (ACA). Our goal is now in reach. Gov. Mike Pence unveiled his new version of the Healthy Indiana Plan, dubbed HIP 2.0, and it appears that it may accomplish exactly what we have been asking for — coverage for 300,000 to 450,000 Hoosiers currently without health insurance.

The public comment period has now closed and the formal application will be submitted to Health and Human Services by the end of the month. Coverage will begin some time in 2015.

We are proud of all we have done. Working with a broad coalition, Cover Indiana, we delivered over 10,000 petition signatures to the governor on Feb. 19, just before he traveled to Washington D.C. to meet with Secretary Sebelius, along with a letter signed by bishops and other religious leaders around the state, and copies of city and county council resolutions (including Bloomington’s) calling for Medicaid expansion. We provided all that information to Secretary Sibelius too. Newspapers across the state printed our letters and op-eds. Legislators and the governor heard our message.

Listen to the language Gov. Pence is using:

“I have long believed that a society may be judged not only by how it deals with its most vulnerable, but also by how it comes alongside those often forgotten working people who are striving every day for a better life.”

“Low-income, working Hoosiers … lack access to the kind of quality health insurance that their better-off neighbors enjoy. Many Hoosiers … cannot access affordable coverage and live in uncertainty.”

“Hoosiers have long-cherished the principle that we must ‘love our neighbor as ourselves;’ that we must not ‘walk by on the opposite side of the road’ when our neighbors are hurting and in need.”

In these words, there is an implicit understanding of the failure of our current system to meet the needs of too many, and an acknowledgement that government must take a larger role in guaranteeing access to healthcare.

The governor has made many statements about market-based reforms and he claims that HIP 2.0 is anything but Medicaid expansion under the ACA. We recognize the political reality of his position, but can only praise him for the political courage he has shown. Ultra-conservatives have lambasted HIP 2.0, asserting that it “isn’t consumer driven in any meaningful sense” (The Federalist) and, “is a Medicaid expansion with some free-market window dressing.” (Forbes).

Be that as it may, if HIP 2.0 goes into effect next year as proposed, it will be the largest expansion of health insurance coverage in Indiana since the passage of Medicare and Medicaid in 1965.

Our work is not done. Medicaid by whatever name is a flawed program, and the ACA is only a step on the way to the ultimate goal, expanded and improved Medicare for all. Everybody in; nobody out.

Robert Stone, M.D., is director of Hoosiers for a Common Sense Health Plan.

http://www.heraldtimesonline.com/news/opinion/hip-replacement-or-onward-with-healthcare-expansion/article_aaede2d9-66dc-5762-9344-62f4e00f433f.html

UnitedHealth’s Premium Physician Designation Program is not about quality

UnitedHealth Premium® Designation Program

The UnitedHealth Premium® physician designation program uses evidence-based, medical society, and national industry standards to recognize physicians for providing quality and cost efficient care.

The following designation results are displayed publicly in UnitedHealthcare’s physician directories (e.g., myuhc.com) to support informed decision-making by members when making health care choices and by physicians when making referrals.

Designation information is as follows:

Quality & Cost Efficiency

Cost Efficiency & Not Enough Data to Assess Quality

Quality & Not Enough Data to Assess Cost Efficiency

Quality & Did Not Meet Cost Efficiency

Not Enough Data to Assess Quality & Did Not Meet Cost Efficiency

Not Enough Data to Assess

Not Evaluated

Did Not Meet Quality & Cost Efficiency

Innovative Benefit Plan Designs

In addition, employers may offer health benefit programs (e.g., reduced cost-sharing or tiered benefit programs) that provide benefit incentives for members to use UnitedHealth Premium Tier 1 physicians.

Members in health plans that offer tiered benefits may pay lower co-pays and co-insurance amounts for services provided by UnitedHealth Premium Tier 1 physicians.

UnitedHealth Premium Tier 1 physicians have received one of the following Premium designations:

Quality & Cost Efficiency

Cost Efficiency & Not Enough Data to Assess Quality

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=a7b046…

****

UnitedHealth Premium® Physician Designation Program

Summary Methodology

The UnitedHealth Premium physician designation program uses clinical information from health care claims and other sources to assist physicians in their continuous practice improvement and to help consumers make more informed and personally appropriate choices for their medical care.

Evaluation for quality compares a physician’s observed practice to the UnitedHealthcare national rate among other physicians who are responsible for the same interventions. Cost efficiency is assessed by comparing the case-mix adjusted cost of care attributed to the physician to a benchmark and applying a statistical test to determine if the difference is statistically significant.

Quality is the fundamental measurement, demonstrating our commitment to evidence-based practice. The quality designation is separate from the cost efficiency designation. Although the quality and cost efficiency evaluations are performed separately, the results are used together to determine the physician’s designation.

Physicians who meet both the quality and cost efficiency designation criteria will receive the quality and cost efficiency designation. Physicians who meet the quality designation criteria will receive the quality designation regardless of their cost efficiency evaluation. Physicians who meet the cost efficiency designation criteria will receive the cost efficiency designation if they do not have enough data to assess quality.

Quality Assessment

A physician’s quality individual outcome is determined by comparing the number of times his/her patients received recommended care with a benchmark number based on the UnitedHealthcare national rate of the same recommended care for each quality measure.

Cost Efficiency Assessment

Episode cost measurement compares a physician’s observed costs for episodes of care to a peer group’s costs for similar episodes of care, with adjustments for the patient’s severity of illness and the physician’s case mix.

For both episode cost and population cost measurement, the physician’s costs within each set are evaluated against their peer group’s costs by ordering the costs from lowest to highest cost. The costs are converted into percentiles to allow comparison across different types of cases or patients.

Physicians’ costs must be statistically significantly lower than the peer group’s physicians at the 75th percentile performance for all physicians (measured in the same specialty for the same types of episodes in the same geographic area) in order to meet the episode cost measurement criteria.

UnitedHealthcare informs members that designations are intended only as a guide when choosing a physician and should not be the sole factor in selecting a physician. As with all programs that evaluate performance based on analysis of a sample, there is a risk of error.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/A…

In support of Medicare for all

By Jack Bernard
The Florida Times-Union (Jacksonville), June 30, 2014

My party, the GOP, is running for election this year on the slogan “repeal and replace Obamacare.”

I agree, but the question is “what will be the replacement?” My answer is Medicare for all.

From a moral standpoint, due to expansion of access to health care, the Affordable Care Act is clearly better than what we had previously. The Medicaid expansion provision, which unfortunately was made voluntary by a politicized Supreme Court, does a lot to help very low-income people who cannot afford insurance premiums.

On the other hand, of the 8 million who signed up for Obamacare nationally through the exchanges, many just switched from existing “limited” insurance policies.

In Georgia (my home), 22 percent of the population (one of the highest rates nationally) was uninsured before Obamacare.

Expanding access

Even if all 8 million had been uninsured, tens of millions are still without insurance and will be for the near future. This fact is especially true in red states like ours that have inexplicably chosen to turn back federal money to expand Medicaid, a purely political decision.

Further, because the Affordable Care Act is built on the defective private insurance model, it will never be very effective or efficient.

And with no Affordable Care Act public option, insurance companies will take advantage of consumers. For example, in the Albany, Ga., area, there is only one insurance company available via the exchange, Blue Cross. Incredibly, rates there are higher than they are in Beverly Hills, Calif.

Thus, many experts believe Obamacare does little to contain costs, the “affordable” portion of the Affordable Care Act, because private insurers are at the core of the program.

As opposed to my fellow Republicans, I do not believe that politically we can just repeal it and go back to what we had.

It is also unrealistic to propose simply doing away with Medicare and Medicaid in their current form as the plan by U.S. Rep, Paul Ryan and others in the GOP propose.

Advocating for this policy will just ensure that the GOP becomes a regional party, permanently losing national elections.

As a proven fiscal conservative, I generally do not like high taxes, especially when public money is going to the wrong places and programs.

Reducing costs

So why do I want to see more government involvement in our health insurance system via Medicare expansion to everyone? Because as opposed to many government programs, Medicare works well. Based on their experience, taxpayers (especially senior citizens like me), like Medicare.

And it is efficient, cutting out marketing and overhead expenses. Medicare has overhead expenses of only 3 percent compared to 20 percent-plus for private insurance companies.

Adding a younger and healthier cohort will automatically lower overall Medicare utilization per patient.

Another factor is the strength that being a single payer gives you in the marketplace. This has proven to be true in Canada, which spends much less than we do per capita and has better outcomes.

Obama, by nature a cautious moderate, made a major mistake in abandoning his previous support for Medicare for all. I believe that he should reverse course and establish a presidential commission to determine the exact benefits and costs of converting our current non-system to single-payer.

Before his retirement, Jack Bernard was a senior health care executive with several national firms as well as the former director of health planning for the state of Georgia.

http://members.jacksonville.com/business/columnists/2014-06-30/story/guest-column-support-medicare-all

Supreme Court decision: Whose religious freedom?

Opinion of the Court

Supreme Court of the United States, June 30, 2014

BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL. v. HOBBY LOBBY STORES, INC., ET AL.

and

CONESTOGA WOOD SPECIALTIES CORPORATION ET AL., PETITIONERS 13–356 v. SYLVIA BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL.

Justice Alito delivered the opinion of the Court.

We must decide in these cases whether the Religious Freedom Restoration Act of 1993 (RFRA), 107 Stat. 1488, 42 U. S. C. §2000bb et seq., permits the United States Department of Health and Human Services (HHS) to demand that three closely held corporations provide health-insurance coverage for methods of contraception that violate the sincerely held religious beliefs of the companies’ owners.

In holding that the HHS mandate is unlawful, we reject HHS’s argument that the owners of the companies forfeited all RFRA protection when they decided to organize their businesses as corporations rather than sole proprietorships or general partnerships. The plain terms of RFRA make it perfectly clear that Congress did not discriminate in this way against men and women who wish to run their businesses as for-profit corporations in the manner required by their religious beliefs.

Since RFRA applies in these cases, we must decide whether the challenged HHS regulations substantially burden the exercise of religion, and we hold that they do.

****

Ginsburg, J., dissenting

Importantly, the decisions whether to claim benefits under the plans are made not by Hobby Lobby or Conestoga, but by the covered employees and dependents, in consultation with their health care providers. Should an employee of Hobby Lobby or Conestoga share the religious beliefs of the Greens and Hahns, she is of course under no compulsion to use the contraceptives in question. But “[n]o individual decision by an employee and her physician — be it to use contraception, treat an infection, or have a hip replaced — is in any meaningful sense [her employer’s] decision or action.” Grote v. Sebelius, 708 F. 3d 850, 865 (CA7 2013) (Rovner, J., dissenting). It is doubtful that Congress, when it specified that burdens must be “substantia[l],” had in mind a linkage thus interrupted by independent decisionmakers (the woman and her health counselor) standing between the challenged government action and the religious exercise claimed to be infringed. Any decision to use contraceptives made by a woman covered under Hobby Lobby’s or Conestoga’s plan will not be propelled by the Government, it will be the woman’s autonomous choice, informed by the physician she consults.

http://www.supremecourt.gov/opinions/13pdf/13-354_olp1.pdf

****

Comment:

By Don McCanne, MD

Allowing an employer to deny coverage of family planning services for employees, strictly on the basis of the employer’s own religion, is yet one more flaw in our highly dysfunctional system of health care financing – a system that is being perpetuated by the Affordable Care Act. If we had a single payer national health program, the employer would not be involved.

As Justice Ginsburg stated in her dissent, a woman’s use of family planning services should be “the woman’s autonomous choice, informed by the physician she consults.” If religious beliefs enter into that decision, it should be the religious beliefs of the individual and not anyone else.

Vermont and its educators lead the way on single payer

By Mary Ellen Flannery
NEA Today, June 27, 2014

The same state that led the nation on same-sex marriage is now tackling another social justice issue: health care coverage for all of its residents.

Led by Gov. Peter Shumlin, with the strong support of VT-NEA and its leaders, the state of Vermont is moving effectively toward becoming the first in the U.S. with a universal, publicly funded healthcare system. Also known as “single payer,” a universal system promises to contain the out-of-control costs of health care while delivering high-quality, comprehensive, and affordable care to all Vermonters, no matter their family income, employment status or background.

“Many people may have been surprised and a little curious (to hear) Vermont-NEA was backing the move toward universal, publicly funded health care,” wrote VT-NEA President Martha Allen this spring. “After all, the thinking goes, members of the state’s largest union already have comprehensive and affordable health insurance, so why on earth would they support Vermont’s efforts to become the first U.S. state to go down this road?

“The answer, of course, is that the creation of Green Mountain Care is good for Vermonters.”

Proponents of universal health care in Vermont, including many doctors and small business owners, began decades ago to pursue a unified health care system. In 2011, they won a key victory: Passage of Act 48, a state law requiring creation of a “universal and unified” health care system for the “public good” of all Vermont residents. Called “Green Mountain Care,” the new program must, by law, cover residents “in a seamless manner regardless of income, assets, health status, or availability of other health coverage.” It also must work to contain costs, provide patients with choices, and preserve and enhance primary care in Vermont’s communities.

“There’s no reason that anybody in Vermont, regardless of who they are, where they work, or what their health status is, should be without comprehensive, affordable health care,” said Mark Hage, VT-NEA’s health-policy expert. “We’ve been a leading player here to expand access to public health care for Vermonters. This has always been important to us as a union. We believe it’s the right thing to do.”

If all goes well with the General Assembly’s next task—finding the money to pay for roughly $2 billion program— Vermonters will be enjoying Green Mountain Care in 2017, the first year that states may be permitted to enact a single-payer system under the federal Affordable Care Act (ACA). At that point, it could be a model for other states interested in following its lead.

“Vermont is a very progressive state,” said Ida Hellender, of the Physicians for a National Health Program. But the essential ingredients of Vermont’s health care system can be found anywhere: “They have doctors, they have hospitals, they have the same kinds of bodies that the rest of us do…”

Opportunity knocks

NEA has long believed that “affordable comprehensive health care … is the right of every resident,” and that belief has been codified among the NEA resolutions adopted by the NEA Representative Assembly (RA) each summer. NEA also has resolved to support a single-payer system for the United States, and to support the reform efforts that will move the U.S. closer to that goal. That includes technical and financial support for the current efforts in Vermont.

There are few things about Vermont that make it a likely pioneer of universal, publicly funded health care. For one thing, with a population of about 625,000, it’s small. (By contrast, its neighbor Massachusetts has 6.6 million residents.) “It’s possible to actually talk to almost every Vermonter about the benefits of Green Mountain Care,” said Peter Sterling, director of Vermont Leads, a nonprofit organization that advocates for universal, publicly funded healthcare. (To sign Vermont Leads’ petition for universal, publicly funded health care for all, or to contribute financially to its advocacy efforts, visit its website.)

For another thing, Sterling pointed out, Vermont already has very popular and very successful state-funded healthcare systems. Its program for kids who live in poverty, “Dr. Dynasaur,” has provided excellent care for 25 years (without deductibles or co-pays), helping to make Vermont’s children “the healthiest kids in the nation,” according to data collected by the U.S. Centers for Disease Control and Prevention. Additionally, another state-funded, comprehensive program called Catamount Health, which existed for several years until the start of Vermont’s ACA-mandated “state exchange,” covered Vermont working families who weren’t Medicaid-eligible.

But 47,000 Vermonters still lacked health insurance at last count, and many tens of thousands more have private insurance but can’t actually afford to use it—and it’s only getting worse for them. Nearly 90,000 Vermonters now pay for their insurance through Vermont Health Connect, an ACA-mandated “state exchange” or online marketplace, and its prices are expected to soar next year. Blue Cross Blue Shield of Vermont, which sells nearly two-thirds of the policies on the state exchange, has asked state regulators for a 9.8 percent increase; its “silver plan” would go from $425 a month to $471.

Vermont and its residents spend almost $5 billion each year on health care costs, up from $2 billion in 2000. Per person, they spent $7,876 in 2010, up from $3,776 in 2000, according to the Green Mountain Care Board.

“I hear from a lot of people who can’t afford the out-of-pocket costs. Nurses tell me that they give their patients dollars, so that they can afford their prescription drugs. If somebody has a $20 co-pay to see their mental-health specialist, they’re just not going to go,” said Sterling. “Vermont is not a wealthy state. A lot of providers are saying that their non-Medicaid eligible patients, lower-middle income people, can’t get the recommended care because they can’t afford the costs.”

Even VT-NEA members aren’t immune from these cost increases. While their collectively bargained contracts often provide affordable, high quality health benefits (in many cases, they have deferred salary increases to keep those benefits), it’s becoming harder to retain these high-quality benefits with premium co-pays that are affordable. Cost pressures, of course, are also hurting retired members. .

Moreover, while most Vermont teachers and educational support professionals are insured through the Vermont Education Health Initiative, a unique health care trust run by VT-NEA and the Vermont School Boards Insurance Trust, eventually certain provisions in the ACA, and in state law, will hasten the dissolution of that trust, compelling almost all of those educators to join the state exchange.

“It won’t happen overnight, but it will happen,” said VT-NEA’s Hage. At that point, what’s already clear should become obvious to all VT-NEA members: The state needs a unified, universal health care system that its residents can actually afford and enjoy. And when that happens, VT-NEA will make sure its members, active and retired, do not suffer in the transition to a universal system.

“Vermont-NEA’s members have been at the forefront of social justice issues for more than a century, and have done great work to ensure that working people and their families are treated fairly, compensated justly and allowed to live with dignity,” said Allen. “We pledge to continue that great tradition and will not waver in our commitment to making sure Green Mountain Care brings comprehensive, affordable benefits for all of us.”

http://neatoday.org/2014/06/27/vermont-and-its-educators-lead-the-way-on-single-payer/

Error on Anthem ID cards results in claim denials

Comment:

Opinion of the Court

Comment:

Footer